Category: Abdominal Imaging, Region: Pelvis-Testis, Plane: Axial
A 35-year-old male presented with left testicular pain and scrotal swelling with fevers and chills. He was distressed, hypertensive at 156/100 mmHg, tachycardic at 122 bpm, but afebrile at 37.6˚C. His penis was normal. He was status post right orchiectomy. The scrotal skin appeared inflamed but not necrotic. His pain was out of proportion to exam. Laboratory studies, including WBC, were normal. Testicular US demonstrated scrotal thickening with subcutaneous emphysema (Figure 1). CT of the abdomen and pelvis confirmed the findings, concerning for necrotizing infection. The right testicle and spermatic cord were absent (Figures 2 and 3). There were little or no inflammatory changes in the pelvic or perineal fat, but this was not initially appreciated. Urology took him emergently to the OR. Surprisingly, upon incision, there was no evidence of any infection. They were understandably confused, and suspected malingering or factitious disorder. Outside hospital (OSH) records revealed that the patient presented there 1 year ago under nearly identical circumstances, and was treated for sepsis and Fournier’s gangrene. Testicular exploration there was also negative for infection. During that admission he was observed surreptitiously injecting his central line and scrotum with contaminated water. Blood cultures grew polymicrobial enteric organisms, with speciation suggesting feces or sewage water injection. When confronted, he admitted presenting to the OSH last year under false circumstances, but that his concern for infection was genuine during this hospitalization. The diagnosis of factitious disorder versus malingering was made, and the patient was discharged.